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Sars and Public Health in Ontario

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THE SARS COMMISSION INTERIM REPORT SARS AND PUBLIC HEALTH IN ONTARIO The Honourable Mr. Justice Archie Campbell Commissioner April 15, 2004 INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Table of Contents Table of Contents Dedication Letter of Transmittal EXECUTIVE SUMMARY................................................................................................................1 1. A Broken System .....................................................................................................................24 2. Reason for Interim Report .....................................................................................................25 3. Hindsight...................................................................................................................................26 4. What Went Right?....................................................................................................................28 5. A Constellation of Problems..................................................................................................30 Problem 1: The Decline of Public Health ...............................................................................32 Problem 2: Lack of Preparedness: The Pandemic Flu Example..........................................37 Problem 3: Lack of Transparency.............................................................................................47 Problem 4: Lack of Provincial Public Health Leadership .....................................................51 Problem 5: Lack of Perceived Independence .........................................................................55 Problem 6: Lack of Public Health Communication Strategy................................................56 Problem 7: Poor Coordination with Federal Government...................................................64 Problem 8: A Dysfunctional Public Health Branch...............................................................72 Problem 9: Lack of Central Public Health Coordination......................................................76 Problem 10: Lack of Central Expertise......................................................................................80 Problem 11: No Established Scientific Backup ........................................................................83 Problem 12: Lack of Laboratory Capacity.................................................................................89 Problem 13: No Provincial Epidemiological Unit....................................................................96 Problem 14: Inadequate Infectious Disease Information Systems ......................................100 Problem 15: Overwhelming and Disorganized Information Demands..............................111 Problem 16: Inadequate Data....................................................................................................114 Problem 17: Duplication of Central Data Systems ................................................................118 Problem 18: Blockages of Vital Information ..........................................................................121 Problem 19: Legal Confusion....................................................................................................126 Problem 20: Public Health Links with Hospitals....................................................................131 Problem 21: Public Health Links with Nurses, Doctors and Others..................................139 Problem 22: Lack of Public Health Surge Capacity: The Toronto Example .....................146 Problem 23: The Case of the Federal Field Epidemiologists ...............................................152 6. Improvements since SARS...................................................................................................156 7. Naylor, Kirby, Walker ...........................................................................................................161 8. Federal-Provincial Cooperation...........................................................................................162 9. Independence and Accountability.......................................................................................163 10. The Public Health Ping-Pong Game ..................................................................................168 11. One Local Funding Problem ...............................................................................................175 12. The Municipalities’ Funding Dilemma ...............................................................................182 13. One Local Story: Parry Sound .............................................................................................183 14. An Ontario Centre for Disease Control.............................................................................186 15. Public Health Restructuring .................................................................................................189 16. Greater Priority for Infectious Disease Control................................................................194 INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Table of Contents 17. Central Control over Health Protection.............................................................................200 18. Twenty-one Principles for Reform .....................................................................................206 19. Political Will............................................................................................................................209 APPENDIX A: THE COMMISSION’S ONGOING WORK..............................................211 APPENDIX B: ORDER IN COUNCIL....................................................................................213 APPENDIX C: LETTER OF APPOINTMENT .....................................................................215 APPENDIX D: TERMS OF REFERENCE .............................................................................217 APPENDIX E: THE ECONOMIC IMPACT OF SARS........................................................219 ii INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Dedication Dedication This report is dedicated to those who died from SARS, those who suffered from it, those who fought the disease, and all those affected by it. INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Letter of Transmittal Letter of Transmittal COMMISSION TO INVESTIGATE 180 Dundas Street West, 22nd Floor Toronto, ON M5G 1Z8 THE INTRODUCTION AND SPREAD OF SARS IN ONTARIO Tel: (416) 212-6878 Fax: (416) 212-6879 Website: www.sarscommission.ca The Honourable Archie Campbell Commissioner April 15, 2004 The Honourable George Smitherman MPP Minister of Health and Long-Term Care 10th Floor Hepburn Block 80 Grosvenor St. Toronto, Ontario M7A 2C4 Dear Mr. Minister: Pursuant to the terms of reference, letter of appointment, and Order-in-Council establishing the independent SARS Commission I submit the attached interim report. Yours truly, Archie Campbell Commissioner INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Executive Summary EXECUTIVE SUMMARY A BROKEN SYSTEM SARS showed that Ontario’s public health system is broken and needs to be fixed. Despite the extraordinary efforts of many dedicated individuals and the strength of many local public health units, the overall system proved woefully inadequate. SARS showed Ontario’s central public health system to be unprepared, fragmented, poorly led, uncoordinated, inadequately resourced, professionally impoverished, and generally incapable of discharging its mandate. The SARS crisis exposed deep fault lines in the structure and capacity of Ontario’s public health system. Having regard to these problems, Ontario was fortunate that SARS was ultimately contained without widespread community transmission or further hospital spread, sickness and death. SARS was contained only by the heroic efforts of dedicated front line health care and public health workers and the assistance of extraordinary managers and medical advisors. They did so with little assistance from the central provincial public health system that should have been there to help them. These problems need urgently to be fixed. REASONS FOR INTERIM REPORT The work of this Commission will continue until I am satisfied that the necessary evidence has been reviewed. Because government decisions about fundamental changes in the public health system are clearly imminent, this interim report on the public health lessons of SARS is being issued at this time instead of awaiting the final report. This interim report is based on the evidence examined to date and is not intended as the last word on this aspect of the Commission’s investigation. The fact that the Commission must address public health renewal on an interim basis is not to say it is more important than any other urgent issue such as the safety and protection of health care workers. It is simply a case of timing. The Commission continues to interview health care workers, SARS victims, the families of those who died, and those who fought the outbreak. Their story and the story of SARS will be told in the Commission’s final report. For an update on the Commission’s ongoing work see Appendix A. TWENTY-ONE PRINCIPLES FOR REFORM The lessons of SARS yield 21 principles for public health reform: 1. Public health in Ontario requires a new mandate, new leadership, and new resources. 1 INTERIM REPORT ♦ SARS AND PUBLIC HEALTH IN ONTARIO Executive Summary 2. Ontario public health requires renewal according to the principles recommended in the Naylor,
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